Frequently Asked Questions

Q: How does the deductible work?
A: All expenses are subject to the deductible and coinsurance except for office visits, which are described below.

Q: What does the office copay cover?
A: Network doctor's office visits will be covered at 100% after a $15 copay for all covered medical expenses performed in the doctor's office, subject to the policy exclusions and limitations. The deductible is waived for doctor's visits. However, the deductible and the 80% coinsurance will apply to any charges performed outside the doctor's office (for example, if billed separately for lab and X-Ray services).

Q: What doctors can I see?
A: Please call the number on the back of your ID card to find a network doctor in your area. You also may print off a personal network directory for your area at www.beechstreet.com. Network providers have agreed to discounted, contracted rates for services, which can SAVE YOU MONEY.

However, you can see any licensed physician. If you choose to go to a non-network provider, you still will be covered under the plan at 80% coinsurance, but you may not receive the PPO network discounts.

Q: What medical expenses will be covered?
A: Examples of covered medical expenses include: hospital bills, doctor bills, prescription drugs, lab and x-ray charges, medical equipment and supplies, therapy, home health care, and hospice inpatient care.

Q: What rules apply?
A: In order to be covered, your medical expense must:
- be administered and ordered by a licensed physician
- be medically necessary for the diagnosis and treatment of a sickness or injury
- not be excluded by the policy.

Q: Is there a pre-existing condition exclusion?
A: Yes. The group health coverage you are applying for may not provide benefits for preexisting conditions for a period of 12 months for persons who are enrolled when first eligible or who enroll during a special enrollment period, or for a period of 18 months for persons who are late enrollees. This period may be reduced if you had previous creditable coverage and furnish PAI with a certificate of creditable coverage. Until this certification is received and a determination is made as to whether or not the person is entitled to a reduced period of preexisting conditions exclusions, any claim submitted for a preexisting condition, incurred during the respective 12 or 18 month periods, will be denied. If a certificate or other evidence of creditable coverage is subsequently received, the claim will be reconsidered.

Q: How are inpatient physician charges covered?
A: Inpatient physician charges (such as surgery, anesthesiology, and doctor visits while admitted to the hospital) are covered at 80% up to the $5,000 annual plan maximum.

Q: What does the Inpatient Limit refer to?
A: This refers to hospital-billed charges, other than room and board, during an inpatient stay. Examples include medications, supplies, etc.

Q: Are birth control pills covered under the medical plan?
A: No, not unless they are required by state law, or are medically necessary for treatment of an illness.

Q: What if I go to the emergency room?
A: Emergency room charges will be covered as any other outpatient expense, subject to the deductible and coinsurance, unless you are admitted to the hospital. If admitted to the hospital, charges will be covered as an inpatient expense.

Q: Will I receive an ID Card?
A: Yes. Once your enrollment is processed, an ID Card will automatically be generated and mailed to your home address. Please allow up to three weeks for delivery. If you have not received a card after three weeks, please contact member services.

Q: Are prescription drugs covered?
A: Yes. Prescription drugs are handled differently, depending on which plan you have. With the standard plan, after you pay for your prescriptions, you can submit the receipt with a claim form for reimbursement under the plan, payable at 80% after deductible, subject to the Outpatient Limit. If you have the Rx Copay plan, then the deductible is waived and you would pay a copay for your prescriptions, and benefits would be paid up to the monthly maximum.

(Some limitations and exclusions apply. Please see your policy for a complete description of coverage.)